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<title>全区医院门诊预约平台---填写预约内容</title>
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            <div class="top03_text">注意</div>
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        	<div class="con05">1. 请您认真填写预约内容，以便我们在您就诊时核对数据；</div>
            <div class="con05">2. 网上预约仅受理次日起七日内预约；</div>
            <div class="con05">3.如预约者需变更预约，请致电变更预约信息；挂号处咨询电话：0771-1234567</div>
            <div class="con05">4.提交成功后将自动产生一个预约号，就诊时在挂号处请出示您的预约号；</div>
        	<div class="con04">承诺： 我们将绝对保障您的个人隐私权，所有个人资料和通话内容一律受到法律保护。</div>
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							<td width="17%">预约时间：</td>
							<td width="22%"><form id="form1" name="form1" method="post" action="">
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							    <input name="textarea2" type="text" value="2009年11月12日下午15时" size="28" />
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							<td width="12%">&nbsp;</td>
							<td width="12%">您的姓名：</td>
							<td width="37%"><form id="form2" name="form2" method="post" action="">
							  <label>
							    <input name="textarea3" type="text" value="张山" />
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							<td>性    别：</td>
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							      <option>男</option>
							      <option>女</option>
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							<td>&nbsp;</td>
							<td>年    龄：</td>
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							    <input name="textarea4" type="text" value="8" size="5" />
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							  岁
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							  <input name="textarea5" type="text" value="北海市安宁大道务实街11号" size="28" />
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							<td>&nbsp;</td>
							<td>联系电话：</td>
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							<td>预约医院：</td>
							<td><form id="form7" name="form7" method="post" action="">
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							    <input name="textarea7" type="text" value="广西医科大第一附属医院"  size="28"/>
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							<td>&nbsp;</td>
							<td>预约科类：</td>
							<td><form id="form8" name="form8" method="post" action="">
							  <label>
							    <input name="textarea8" type="text" value="眼科" />
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							<td>预约医院地址：</td>
							<td><form id="form9" name="form9" method="post" action="">
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							    <input name="textarea9" type="text" value="广西南宁市大学东路001号" size="28"/>
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							<td>&nbsp;</td>
							<td>&nbsp;</td>
							<td>&nbsp;</td>
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							<td>预约医生：</td>
							<td><form id="form10" name="form10" method="post" action="">
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							      <option>眼科</option>
							      <option>儿科</option>
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							<td colspan="3" class="td"><form id="form11" name="form11" method="post" action="">
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							    <select name="select3">
							      <option>刘三医生</option>
						        </select>
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							  <a href="time.html">查看医生门诊时间表</a>
							</form>							</td>
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							<td>预约留言：</td>
							<td><span class="STYLE1">备注：说明少于500字</span></td>
							<td>&nbsp;</td>
							<td>&nbsp;</td>
							<td>&nbsp;</td>
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							<td colspan="4"><form id="form12" name="form12" method="post" action="">
							  <label>
							    <textarea name="textarea10" cols="50" rows="5">患有红眼病三天。</textarea>
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